General approaches toward examining the child (sequence, communication, age appropriate approach/techniques) Johanna
Sequence of Examination
Just as with the adult patient, the sequence for performing the physical assessment of the child normally proceeds in a head-to-toe manner. However, this sequence may need to be altered depending upon the child's age, whether or not they're in pain, and if any obvious physical deformities are present. As a general rule of thumb, the affected area (or part that is painful or injured) should be examined last to minimize the stress of the overall examination. Here are a few guidelines for exam sequences of different age groups.
Infants: Ausculate the heart, lungs, and abdomen first while the baby is peaceful and quite. Record the heart and respiratory rates. Palpate and percuss those same areas, then proceed in the usual head to toe manner. Perform the more traumatic procedures towards the end of the exam and test the moro reflex LAST.
Toddler: Inspect the body areas though play first; tickle the toes, count the fingers. Begin using touch slowly so as not to frighten the child, and allow the child time to get used to equipment. Take advantage of any quite moments and use them to auscultate, percuss, and palpate. Perform the more traumatic procedures last, just like with the infant.
Preschooler: If the child is cooperative, you can proceed in the normal head-to-toe manner. If they aren't cooperating, use the same sequence as with the toddler.
School-Aged Child: Proceed in the head-to-toe manner, but examine the genitalia last. Respect that children of this age have a need for privacy. Allow them to leave their underpants on if they want to.
Adolescents: Same as with the school-aged child. Allow the adolescent to undress in private.
Communication
The first thing a nurse should do when entering the exam room is to introduce themselves to the parent(s) and child. To foster effective communication, it is best to ask open-ended questions, especially if you sense that the parents may have difficulty in discussing their child's illness. The most important factor to remember when communicating with the child is their developmental level. With younger (smaller!) kids, remember to get down to their eye level when speaking to them, and remember that younger children (toddler thru preschool aged) are very egocentic. It is best to therefore focus your communication on them. Remember that children of this age often believe that inanimate objects (like a stethoscope) are alive, this is called animism. It might be a good idea to keep scary instruments out of sight in the exam room. Older children will benefit from you explaining how the instruments work in simple terms, they may also be interested in and able to understand the exam findings. Share these with them in terms they will understand.
Encouraging Cooperation
Most of the time children cooperate the best when a parent stays present in the exam room, although an adolescent (or even an older school-aged child) may prefer to be alone for the examination. It is best to ask older children what they are most comfortable with. Observe for the following signs that the child is ready to cooperate with the assessment:
Eye contact
Talking to the nurse
Accepting the offered equipment to play with
Allowing physical touching
Choosing to sit on the exam table instead of the parent's lap
If the child does not show signs of being ready or appears fearful, you can try to tell a funny story, perform a magic trick, or using a hand puppet to talk to the child for you. Always keep in mind that a child who is really scared may have had a traumatic experience in the past. Be sensitive to this. Use a firm yet calm voice and perform the exam as quickly as possible.
Children are naturally curious. Include them as much as possible in the exam process; allow them to touch and handle the equipment and explain procedures to them in age-appropriate terms.
Sequence of Examination
Just as with the adult patient, the sequence for performing the physical assessment of the child normally proceeds in a head-to-toe manner. However, this sequence may need to be altered depending upon the child's age, whether or not they're in pain, and if any obvious physical deformities are present. As a general rule of thumb, the affected area (or part that is painful or injured) should be examined last to minimize the stress of the overall examination. Here are a few guidelines for exam sequences of different age groups.
Infants: Ausculate the heart, lungs, and abdomen first while the baby is peaceful and quite. Record the heart and respiratory rates. Palpate and percuss those same areas, then proceed in the usual head to toe manner. Perform the more traumatic procedures towards the end of the exam and test the moro reflex LAST.
Toddler: Inspect the body areas though play first; tickle the toes, count the fingers. Begin using touch slowly so as not to frighten the child, and allow the child time to get used to equipment. Take advantage of any quite moments and use them to auscultate, percuss, and palpate. Perform the more traumatic procedures last, just like with the infant.
Preschooler: If the child is cooperative, you can proceed in the normal head-to-toe manner. If they aren't cooperating, use the same sequence as with the toddler.
School-Aged Child: Proceed in the head-to-toe manner, but examine the genitalia last. Respect that children of this age have a need for privacy. Allow them to leave their underpants on if they want to.
Adolescents: Same as with the school-aged child. Allow the adolescent to undress in private.
Communication
The first thing a nurse should do when entering the exam room is to introduce themselves to the parent(s) and child. To foster effective communication, it is best to ask open-ended questions, especially if you sense that the parents may have difficulty in discussing their child's illness. The most important factor to remember when communicating with the child is their developmental level. With younger (smaller!) kids, remember to get down to their eye level when speaking to them, and remember that younger children (toddler thru preschool aged) are very egocentic. It is best to therefore focus your communication on them. Remember that children of this age often believe that inanimate objects (like a stethoscope) are alive, this is called animism. It might be a good idea to keep scary instruments out of sight in the exam room. Older children will benefit from you explaining how the instruments work in simple terms, they may also be interested in and able to understand the exam findings. Share these with them in terms they will understand.
Encouraging Cooperation
Most of the time children cooperate the best when a parent stays present in the exam room, although an adolescent (or even an older school-aged child) may prefer to be alone for the examination. It is best to ask older children what they are most comfortable with. Observe for the following signs that the child is ready to cooperate with the assessment:
If the child does not show signs of being ready or appears fearful, you can try to tell a funny story, perform a magic trick, or using a hand puppet to talk to the child for you. Always keep in mind that a child who is really scared may have had a traumatic experience in the past. Be sensitive to this. Use a firm yet calm voice and perform the exam as quickly as possible.
Children are naturally curious. Include them as much as possible in the exam process; allow them to touch and handle the equipment and explain procedures to them in age-appropriate terms.